           
<div class="field-row add-patient-row">
    <div class="field-label add-patient-label" style="width: 150px;">{translate}Health insurance No.{/translate}</div>
    <div class="field-value add-patient-value" style="width: 270px;">
        <input type="text" style="width: 25px;" id="insuranceCode_0" name="insuranceCode_0" maxlength="2" value="{$insuranceCode.1}">
        <input type="text" style="width: 25px;" id="insuranceCode_1" name="insuranceCode_1" maxlength="1" value="{$insuranceCode.2}">
        <input type="text" style="width: 25px;" id="insuranceCode_2" name="insuranceCode_2" maxlength="2" value="{$insuranceCode.3}">
        <input type="text" style="width: 25px;" id="insuranceCode_3" name="insuranceCode_3" maxlength="2" value="{$insuranceCode.4}">
        <input type="text" style="width: 40px;" id="insuranceCode_4" name="insuranceCode_4" maxlength="3" value="{$insuranceCode.5}">
        <input type="text" style="width: 50px;" id="insuranceCode_5" name="insuranceCode_5" maxlength="5" value="{$insuranceCode.6}">
    </div>  
    <div style="clear: both;"></div>
</div>

<div class="field-row add-patient-row" style="padding-top: 5px;">
    <div class="field-label add-patient-label" style="width: 150px;">{translate}Usage time{/translate}</div>
    <div class="field-value add-patient-value" id="usageTimeContainer">
        <input type="text" name="issued_{$datePart_0}" id="issued_{$datePart_0}" style="width: 25px;" maxlength="2" value="{$date_issued.0}"> 
        <input type="text" name="issued_{$datePart_1}" id="issued_{$datePart_1}" style="width: 25px;" maxlength="2" value="{$date_issued.1}">
        <input type="text" name="issued_{$datePart_2}" id="issued_{$datePart_2}" style="width: 40px;" maxlength="4" value="{$date_issued.2}">
        <span class="label"> - </span>
        <input type="text" name="expired_{$datePart_0}" id="expired_{$datePart_0}" style="width: 25px;" maxlength="2" value="{$date_expired.0}"> 
        <input type="text" name="expired_{$datePart_1}" id="expired_{$datePart_1}" style="width: 25px;" maxlength="2" value="{$date_expired.1}">
        <input type="text" name="expired_{$datePart_2}" id="expired_{$datePart_2}" style="width: 40px;" maxlength="4" value="{$date_expired.2}">
        <span class="label" style="width: 21px; color: #AAA;">({$datePart_0}-{$datePart_1}-{$datePart_2})</span>
    </div>
     <div style="clear: both;"></div>
</div>

<div class="field-row add-patient-row" style="padding-top: 5px;">
    <div class="field-label add-patient-label" style="width: 150px;">{translate}Registered hospital{/translate}</div>
    <div class="field-value add-patient-value" style="width: 270px;">
        <input type="hidden" name="registeredHospitalId" id="registeredHospitalId" value=""></input>
        <input type="text" name="registeredHospital"  id="registeredHospital" style="width: 245px;" value="{$hospitalName}" onkeyup="return moveNext(event, this.id, null)">
    </div>
    <div style="clear: both;"></div>
</div>